QUALITY OF CARE, HEALTH SYSTEM ERRORS, AND NURSES
Nurses have a major responsibility for the quality of care provided to people.
Why? Because nurses comprise the largest component of the healthcare workforce and are heavily involved with the professional management and provision of care. Nurses are accountable for much of the health care provided in many countries and for the design of health systems through which care is delivered, quality is assured, and errors are avoided.
The US Institute of Medicine (IOM) defines quality as ‘The degree to which health services for individuals and populations increase the likelihood of desired health care outcomes and are consistent with current knowledge.’ Four types of quality-related problems compromise the quality of care: avoidable errors, underuse of services, overuse of services, and practice variance.
In the United States it is estimated that at least 98 000 deaths occur each year because of one or more types of health system errors. Several studies suggest that these errors, of all types, are the eighth leading cause of death in the United States.
Last fall, the Institute of Medicine released a report on errors entitled, To Err is Human, which got everyone's attention. In the report, patient safety is defined as freedom from accidental injury, and error as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. The report concluded that errors are widespread and pose a significant threat to patient safety and that many things we currently do in health systems to prevent errors are not particularly effective.
One of the things we do, which is not effective, is attach blame to individuals for the errors committed. And this is the crux of the problem! The world's foremost authority on errors, Lucien Leape, says, ‘Stop the blame game! Think systems! Ask, ‘What happened?’ not ‘Who did it?’ Throughout his years of study of errors in health care he finds that everyone makes errors every day. Some of these errors are the result of misconduct. But very few. The problem, rather, is system design and function.
Health systems are very complex. Hospitals, for example are among the most complex organizations on earth. And many hospitals throughout the world lack adequate coordination and mechanisms to ensure patient safety. Consider, for example, the incomplete information most practitioners have about people's medication and previous illnesses. Yet despite the evidence we now have that systems fail, managers and other authorities continue to blame the person who gives the wrong medication, or the one who hangs the wrong IV.
Expert evidence and the efforts of thoughtful researchers shows us that instead of blaming nurses and doctors, instead of pointing the finger and alleging misconduct, we must understand, to a much greater degree than we do presently, the basics of health systems so that we can more easily identify then eliminate problems with organization design and maintenance.
Dr Leape suggests that we design work with the human factor in mind and construct an organization that avoids reliance on a person's memory; that simplifies even the most complex tasks; that we standardize; that we create forcing functions by designing so that it is difficult, even impossible to do the wrong thing; and that we use protocols wisely and with logic.
Nurses work long hours. Their workload is often excessive. They must often make decisions with incomplete information and spotty feedback. There is hurry, fatigue, anxiety, and fear. There are system design problems and defects that trigger unsafe acts and the resulting errors and accidents.
Think systems! We are doing better at this level of thinking in nursing but we have a long way to go!
The building blocks and design logic of organizations must be part of every nurse's education and training. Nurse managers must be trained in the basics of system functioning and maintenance. Standards, procedures, rules with an emphasis on making it easy, not complex are required. Automation can be greatly improved. Teamwork can be reformulated so that doctors and nurses and pharmacists truly work together not just side by side. Best practices can be identified and implemented. And traditional roles should be rethought — to reduce all types of errors, to improve the quality of care, to lessen human suffering.